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Vulnerable patient groups

Vulnerable patient groups. Slide resource set. Risk factors for a recurrence of Clostridium difficile infection (CDI). Hu MY, et al. Gastroenterology 2009;136:1206–14; Do AN, et al. Clin Infect Dis 1998;26:954–9; Bauer MP, et al. Clin Microbiol Infect 2011;17(Suppl 4):A1–4;

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Vulnerable patient groups

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  1. Vulnerable patient groups Slide resource set

  2. Risk factors for a recurrence of Clostridium difficile infection (CDI) Hu MY, et al. Gastroenterology 2009;136:1206–14; Do AN, et al. Clin Infect Dis 1998;26:954–9; Bauer MP, et al. Clin Microbiol Infect 2011;17(Suppl 4):A1–4; Pépin J, et al. Clin Infect Dis 2005;40:1591–7. Immunocompromised state1 Exposure to other antibacterial agents that disrupt the normal colonic microflora2–5 Renal impairment6,7 Aged 65 years or over2,4,8 Impaired immune response to C. difficiletoxin A2 Severe underlying disease2 Prolonged hospitalisation8 Intensive care unit (ICU) stay5 Cohen MB. J Pediatr Gastroenterol Nutr 2009;48(Suppl 2):S63–5; Kyne L, et al. Lancet 2001;357:189–93; Bauer MP, et al. Clin Microbiol Infect 2009;15:1067–79; Bauer MP, et al. Lancet 2011;377:63–73; FDX/12/0076/EUr| SJ204

  3. Age-specific incidence of CDI and attributable mortality Loo VG, et al. N Engl J Med 2005;353:442–9. FDX/12/0076/EUb | SJ113

  4. Risk factors among hematopoietic stem cell transplant (HSCT) recipients for CDI Multiple antibiotic courses (cephalosporins, quinolones)1,2 Altered integrity of intestinal mucosa (chemotherapy/total body irradiation)1–3 Source of stem cells: cord blood3 Vancomycin-resistant enterococci (VRE) colonisation2 Renal impairment2 Acute graft versus host disease (GvHD)1–3 Immune suppression (pre-engraftment phase)4,5 Diabetes mellitus5 Prolonged and repeated hospital stays1,4 Bobak D, et al. Bone Marrow Transplant 2008;42:705–13; Alonso CD, et al. Clin Infect Dis 2012;54:1053–63; Willems L, et al. Biol Blood Marrow Transplant 2012;18:1295–301; Anathakrishnan AN. Nat Rev Gastroenterol Hepatol 2011;8:17–26; Dubberke ER, et al. Clin Transplant 2010;24:192–8. AI/12/0055/EUg| DM110

  5. Incidence of CDI in HSCT recipients aEpisodes of diarrhoea per number of patients in the study population; bTotalnumber of infectious complications; cEverypatient had at least one episode of diarrhoea; HSCT, haematopoietic stem cell transplantation;NG, not given Bobak D, et al. Bone Marrow Transplant 2008;42:705–13. FDX/12/0076/EUo|CS201

  6. Epidemiology and outcomes of CDI in HSCT recipients: USA, 2003 to 2008 Autologous (N=489) [overall incidence, 6.5%] 20 Allogeneic (N=510) [overall incidence, 12.5%] All transplants (N=999) [overall incidence, 9.2%] 16 12 CDI incidence (%) 8 4 0 2003 2004 2005 2006 2007 2008 Year • Overall CDI incidence did not vary significantly from 2003 to 2008 Alonso CD, et al. Clin Infect Dis 2012;54:1053–63. 1-year incidence of CDI by transplant type AI/12/0055/EUg| DM112

  7. Timing of CDI by HSCT type Autologous(n=30) Graft type 6.5 days Allogeneic(n=62) 33 days −30 0 30 60 90 120 150 180 210 240 270 300 330 360 12 10 Time to CDI (days) 8 Number of cases 6 4 2 0 0 7 14 21 28 35 42 49 56 63 70 77 84 Day of transplant −7 Median time of onset Alonso CD, et al. Clin Infect Dis 2012;54:1053–63. AI/12/0055/EUg| DM113

  8. Acute GvHD among allogeneic HSCT recipients with and without CDI The 1-year probability of developing grade 2 or higher gastrointestinal GvHDwas 25% in case patients and 4.6% in control patients (log-rank test; p=0.0001) 0.28 CDI No CDI 0.24 0.20 0.16 Cumulative probability of acute GI GvHD (grade 2 or higher) 0.12 0.08 0.04 0.00 0 25 50 75 100 125 150 175 200 225 250 275 300 325 350 375 Time from stem cell transplant (days) GI, gastrointestinal; GvHD, graft versus host disease Alonso CD, et al. Clin Infect Dis 2012;54:1053–63. FDX/12/0076/EUo | CS221

  9. Survival among allogeneic HSCT recipients with and without CDI Kaplan–Meier graph of overall survival following allogeneic HSCT depending on the presence or absence of CDI 1.2 1.0 0.8 No CDI (n=65) Cumulative survival 0.6 CDI (n=10) 0.4 0.2 0.0 0 10 20 30 40 50 60 Time (months) Median survival was 100 days in patients with CDI vs 41 months in patients without CDI (p=0.01) Chakrabarti S, et al. Bone Marrow Transplant 2000;26:871–6. AI/12/0055/EUg| DM115

  10. Rates of CDI in patients with inflammatory bowel disease (IBD) Ulcerative colitis Non-IBD GI patients 60 Crohn’s disease All hospital patients 50 40 CDIcases per 1,000 admissions 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 Year • Patients with IBD, particularly those with ulcerative colitis, exhibited greater increases in rates of CDI vs other hospitalised subpopulations Rates of CDI among hospitalised patients with IBD Nguyen GC, et al. Am J Gastroenterol 2008;103:1443–50. GI, gastrointestinal FDX/12/0076/EUd|DN126

  11. Liver transplant patients and CDI • Data from a US nationwide survey involving193,174 hospital discharges from 2004 to 2008 p<0.001 Adapted from Ali M, et al. Liver Transpl 2012;18:972–8. CDI was associated with higher mortality among liver transplant recipients vs non-transplant patients (5.5% vs3.2%, p<0.001) FDX/13/0034/EU | ACE12

  12. Solid organ transplant (SOT) patients and CDI Outcomes of patients with SOT and CDI *The data were evaluated using univariate regression analyses; IQR, interquartile range Pant C, et al. Transpl Infect Dis 2012;14:540–7. FDX/13/0034/EU | ACE13

  13. Kidney transplant patients and CDI Major predictors for CDI: results of multivariate analysis CDC, Centers for Disease Control and Prevention; KTR, kidney transplant recipient; VRE, vancomycin-resistant enterococci The overall rate of CDI among all KTRs was 6.1% (37 of 603) The rate of CDI among KTRs increased from 3.7% (6/161) in 2008 to 9.4% (19/201) in 2010 (p<0.05) Neofytos D, et al. Transpl Infect Dis 2013;15:134–41. FDX/13/0034/EU | ACE14

  14. Lung transplant patients and CDI p<0.0001 CDI incidence rate was 224.6 cases/100,000 patient-days for lung transplant patients (n=159) compared with 110 cases/100,000 patient-days (average rate for the entire hospital) Lee JT, et al. Clin Transplant 2013;27:303–10. FDX/13/0034/EU | ACE17

  15. Clinical cure in patients with renal impairment Post hoc analysis; data from pooled analysis; Calculated creatinine clearance used to categorise patients as exhibiting no renal impairment (>90 mL/min/1.73 m2) or stage 2 (60–89 mL/min/1.73 m2), stage 3 (30–59 mL/min/1.73 m2) or stage 4 (<30 mL/min/1.73 m2) chronic kidney disease Of 1,054 patients treated with fidaxomicin or vancomycin, 57.9% had abnormal renal function at baseline 27.4% had stage 2 chronic kidney disease (CKD) 21.3% had stage 3 CKD 9.1% had stage 4 or higher CKD Clinical cure rates (irrespective of treatment) were unaffected by mild renal impairment 91% in patients with normal renal function 92% in patients with stage 2 CKD 80% in patients with stage 3 CKD 75% in patients with stage 4 or higher CKD Cure rates were similar for fidaxomicin and vancomycin at each CKD level Mullane KM, et al. Am J Nephrol 2013;38:1–11. EPG10

  16. Impact of cancer on response to treatment p<0.001 p=0.693 p=0.020 Rate (%) Cornely OA, et al. J Clin Oncol 2013;31:2493–9. Post hoc analysis of pooled data EPG11

  17. Time to resolution of diarrhoea: patients with and without cancer p<0.001 Cornely OA, et al. J Clin Oncol 2013;31:2493–9. Post hoc analysis of pooled data EPG12

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